Characteristics and treatment analysis of young acute coronary syndrome patients in a tertiary care hospital: A cross‐sectional retrospective study

Abstract Background and Aims The prevalence of acute coronary syndrome (ACS) has been rising in the younger population worldwide. To fully comprehend the effects of the condition, it is crucial to examine the evolving characteristics and treatment options. The purpose of this study is to evaluate the characteristics and treatment analysis for young ACS patients in a tertiary care setting. Methods This cross‐sectional, retrospective, single‐center study included a random sample of patients who had been hospitalized for ACS over the period of a year. We collected and analyzed data on risk factors, diagnoses, angiographic patterns, and potential treatments. Results The study involved 198 young ACS patients in total. The majority of patients (57%) had no risk factors, and the majority of them (44%) had ST‐elevation myocardial infarction (STEMI) as their diagnosis. The most common type (48%) was single‐vessel disease (SVD). Statins and antiplatelet medications made up the majority of the patients’ nonsurgical treatments (88% and 87%, respectively). A statistically significant difference exists between young and older ACS patients with gender (p < 0.01). However, it is not clinically relevant. Conclusion Men were the majority of young ACS patients, and STEMI, SVD were more prevalent. The majority of young ACS patients had no significant risk factors. To determine the risk factors of young ACS patients, a more thorough case–control study is critically needed.


| INTRODUCTION
The leading global cause of morbidity and mortality is coronary artery disease (CAD). Acute coronary syndrome (ACS) and symptomatic CAD are uncommon among young adults under the age of 40, despite the fact that atherosclerosis, the primary cause of CAD, develops in the early stages of life. 1 Patients with CAD under the age of 40 represent a special population subgroup that deserves attention. The majority of research has used age 45 as the cut-off date to identify young people with CAD and myocardial infarction (MI). 2 Unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and STsegment elevation myocardial infarction (STEMI) are all included in the clinical spectrum of ischemic heart disease known as ACS. The prevalence of ACS among young people is quite modest when compared with the elderly. 3 India has one of the highest rates of cardiovascular disease (CVD) compared with other countries. 4 According to estimates, throughout the past several decades, the prevalence rates in India have varied between 1.6% and 7.4% for rural populations and between 1% and 13.2% for urban populations. 5 Few studies have focused on the clinical presentation, treatment, angiographic profile, and prognosis of ACS in young patients because CAD occurs often in middle-aged and elderly individuals. 4,[6][7][8][9][10] According to the literature review, young people with ACS are more likely to have cardiovascular risk factors such as smoking, hyperlipidemia, obesity, and a family history of CAD. 3,[11][12][13][14][15][16][17] In India, particularly in urban areas, the prevalence of CVD risk factors has considerably increased during the past 25 years. 18 Over the past 40 years, a considerable decline in CAD mortality rates has been attributed to the identification of risk factors as well as technological advancements in medicine. Thus, the purpose of this study is to evaluate the characteristics and analyses of the treatment of young patients with ACS at a tertiary care hospital in an urban location.

| Selection criteria
The study included all ACS patients who were hospitalized to the cardiology department for coronary angiography, regardless of gender. Patients who passed away before a diagnostic angiography, those with a history of past ACS or coronary revascularization, and more were excluded.

| Study procedure
A specially designed data collection form was used to gather information on demographics, current smoking status, risk factors, clinical presentation, laboratory investigation, coronary angiography, treatment, and drug chart. Obesity is calculated using body mass index (BMI). Information on comorbid conditions was gathered from case files including past medical and medication histories. Laboratory results were also used to confirm in few cases.

| Statistical analysis
The collected data were analyzed using Statistical Package for the Social Sciences (SPSS), version 21.0. Baseline characteristics were expressed as descriptive statistics. Categorical data were expressed as frequencies and percentages. The association between CAM usage and various variables like child's age and gender, parent's or caregivers' education, occupation and socioeconomic status was assessed using the χ 2 test. A p value of less than 0.05 was considered statistically significant.

| RESULTS
The study initially identified 500 consecutive patients who met the inclusion criteria. On further evaluation, 79 cases were excluded owing to insufficient documentation. The remaining 421 cases were included for this study. Of them, 198 were young ACS and their demographic details are given in Table 1. Most patients (57%) were devoid of the typical risk factors. However, as a secondary risk factor, diabetes, hypertension, and dyslipidemia contributed to approximately 17%, 13%, and 5% of cases, respectively. Furthermore, smoking, family history, and obesity represented only 3% of the total risk in our study, making it the least dangerous risk factor. The surgical treatments and medical management were listed in Table 2. A total of 58% of study patients underwent no surgical surgery, whereas 37% underwent percutaneous coronary intervention (PCI) and 5% underwent coronary artery bypass grafting. When pharmacological therapies were examined, statins (88%) such as atorvastatin and rosuvastatin were the most frequently utilized forms of therapy, followed by antiplatelet drugs (87%) such as aspirin, and clopidogrel. Anticoagulants (23%) such heparin and other antianginals (15%) were used sparingly as a type of therapy in patients with ACS. Table 3 shows the baseline characteristics of young (<40 years) and old (>40 years) ACS patients. Except for gender, which indicated a statistically significant difference between the two groups (p < 0.05 with a χ 2 value of 0.06), other variables were distributed equally between the two groups. Although gender difference is statistically significant between the groups, there is no clinically relevant difference because there are more male patients in both the groups.  Anti-coagulants 40 23 Other anti-anginals 30 15 Abbreviations: ACE, angiotensin-converting enzyme; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention. Unlike other studies (Esteban et al., 22 Hamm et al., 23 Schoenenberger et al., 24 ), this study compares the magnitude of various risk factors and treatment pattern that is present in the young acute coronary artery syndrome patients in a retrospective manner so as to audit tool for comparison of the established data with current or future practice. Similar to previous studies (Mirza et al. 25 ), this study on analyzing the demographic variables found that the disease was more prevalent in male population less than 40 years of age which could imply that the age and gender plays a predominant role in modifying the disease progression in an indirect manner.
In contrast to a study conducted in Bangladesh by Patwary et al., 26 27 Wadkar et al., 28 and Sharma et al., 29 whereas NSTEMI and UA were more common in Hoo et al., 30 Iragavarapu et al. 31 The most frequent angiographic procedure in this study is SVD, which is comparable to studies by Pathak et al., 32 Suresh et al., 33 and Al-Koubaisy et al. 34 The LAD contributed 21% of the total volume of the vessels implicated in younger age groups in Badran et al. 35 and Ahmed Hussein et al., 36 studies, which are similar to this study. However, Kennelly et al. 37 reported that the RCA was the most often affected artery. Similar to Jamil et al. 38 and Sricharan et al., 39 TVD is uncommon among the study population.
The results of this study showed that statins (88%) were used to manage most of the patients, followed by antiplatelet drugs. Betablockers, however, were the first preferred choice of medication in research by Davis et al. 40 Aspirin (98%) and statins (81%) were the two most widely used medications for adults under the age of 45, according to Tungsubutra et al. 14 study. The majority of patients in this study did not receive any surgical treatment. According to a study by Schoenenberger et al., 24 PCI was the treatment of choice for young ACS patients. Catheterization was reported in Davis et al. 40 Our study exhibits potential limitations. First, it was a singlecenter study with a small sample size, hence the results cannot be generalized to the community. Second, this is a retrospective study of data and hence confounding factors could not be taken into account.
Moreover, most of the patients had no risk factors so the association between risk factors and young ACS could not be determined.

ACKNOWLEDGMENTS
The authors would like to thank the Tamil Nadu Pharmaceutical Sciences Welfare Trust for funding and awarding "G. Rangachari Memorial (PG Pharmacy Fellowship) Award" for the academic year 2020-2021 for this study.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All the authors have read and approved the final version of the manuscript. Corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data.

TRANSPARENCY STATEMENT
The lead author Muhasarparur Ganesan Rajanandh affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.